Infección nosocomial en el postoperatorio inmediato del trasplante cardiaco: factores de riesgo y tendencia temporal

Programa Oficial de Doctorado en Ciencias de la Salud. 5007V01[Resumen] OBJETIVOS: El objetivo principal de este trabajo es identificar factores de riesgo para el desarrollo de infección precoz postoperatoria tras la cirugía del trasplante cardiaco (TC) y desarrollar un modelo predictivo multivariable para pronosticar esta complicación. MÉTODOS: Se llevó a cabo un estudio unicéntrico, observacional y retrospectivo, considerando como variable dependiente la infección nosocomial postoperatoria. Como variables independientes se recopilaron características demográficas y epidemiológicas de donante y receptor, condiciones quirúrgicas y eventos perioperatorios. Se llevó a cabo un análisis mediante regresión logística para identificar los posibles factores de riesgo. RESULTADOS: Se incluyeron 677 trasplantados, con 348 episodios de infección postoperatoria en 239 pacientes. Se identificaron siete variables independientes como predictores de infección precoz postoperatoria: los antecedentes de diabetes mellitus y esternotomía previa, la ventilación mecánica invasiva (VMI) preoperatoria, el fracaso primario del injerto, el sangrado quirúrgico excesivo y el empleo de mofetil micofenolato (MMF) y de itraconazol. En base a estos resultados, se diseñó un score predictivo que permite pronosticar el riesgo de infección nosocomial postoperatoria en nuestra población con una calibración y capacidad discriminativa apropiadas. CONCLUSIONES: La infección nosocomial en el postoperatorio inmediato del TC es una complicación frecuente. La diabetes mellitus, la esternotomía previa, la VMI preoperatoria, el fracaso primario del injerto, el sangrado quirúrgico excesivo y el empleo de MMF e itraconazol se han identificado como factores de riesgo independientes de la misma[Resumo] OBXECTIVOS: O obxectivo principal deste traballo é identificar factores de risco para o desenvolvemento da infección precoz postoperatoria, antes da alta hospitalaria, tras un TC e desenvolver un modelo predictivo multivariable que permita sinalar o risco de infección nestes pacientes. MÉTODOS: Realizouse un estudo unicéntrico, observacional e retrospectivo, considerando a infección nosocomial postoperatoria como a variable dependente. Como variables independentes, recolléronse características demográficas e epidemiolóxicas de doante e receptor, condicións cirúrxicas e eventos perioperatorios. Levouse a cabo unha análise mediante regresión loxística para identificar os posibles factores de risco. RESULTADOS: Incluíronse 677 trasplantados, con 348 episodios de infección postoperatoria en 239 pacientes. Identificáronse sete variables independentes como predictores da infección precoz postoperatoria: os antecedentes de diabetes mellitus e esternotomía previa, a VMI preoperatoria, o fracaso primario do enxerto, o sangrado cirúrxico excesivo e o emprego de MMF e itraconazol. Seguindo estes resultados, deseñouse unha escala para identificar o risco de infección nosocomial postoperatoria. CONCLUSIÓNS: A infección nosocomial no postoperatorio inmediato do TC é frecuente. A diabetes mellitus, esternotomía previa, a VMI preoperatoria, o fracaso primario do enxerto, o sangrado cirúrxico excesivo e o emprego de MMF e itraconazol identificáronse como factores de risco independentes da infección precoz postoperatoria.[Abstract] OBJECTIVES: The aim of this study was to identify specific risk factors for early postoperative infections in heart transplantation recipients, and to develop a multivariable predictive model to identify patients at high risk. METHODS: A single-centre, observational, retrospective study was conducted. The dependent variable was in-hospital postoperative infection. We examined demographic and epidemiological data from donor and recipients, surgical features and adverse postoperative events as independent variables. Backward, stepwise multivariable logistic regression with a p-value < 0.05 was used to identify clinical factors independently associated with the risk of postoperative infections. RESULTS: 677 patients were included. During the in-hospital postoperative period, 348 episodes of infection were diagnosed in 239 patients. Seven variables were identified as independent clinical predictors of early postoperative infection: diabetes mellitus, previous sternotomy, preoperative mechanical ventilation, primary graft failure, major surgical bleeding, use of mycophenolate mofetil and itraconazole. Base don these results, we constructed a score to predict the risk of in-hospital postoperative infection, which showed a reasonable ability to predict it. CONCLUSIONS: In-hospital postoperative infection is a common complication after heart transplantation. Diabetes mellitus, previous sternotomy, preoperative mechanical ventilation, primary graft failure, major surgical bleeding, mycophenolate mofetil and itraconazole were all independent clinical predictors of early postoperative infectio

Epidemiología y pronóstico de los pacientes con VIH ingresados en la UCI en la era de tratamiento antirretroviral de gran actividad actual

Observational study[Abstract] Purpose: To describe the epidemiology of critical disease in HIV-infected patients during the current highly active antiretroviral therapy (HAART) era and to identify hospital mortality predictors. Methods: A longitudinal, retrospective observational study was made of HIV-infected adults admitted to the ICU in two Spanish hospitals between 1 January 2000 and 31 December 2014. Demographic and HIV-related variables were analyzed, together with comorbidities, severity scores, reasons for admission and need for organ support. The chi-squared test was used to compare categorical variables, while continuous variables were contrasted with the Student's t-test, Mann-Whitney U-test or Kruskal-Wallis test, assuming an alpha level=0.05. Multivariate logistic regression analysis was used to calculate odds ratios for assessing correlations to mortality during hospital stay. Joinpoint regression analysis was used to study mortality trends over time. Results: A total of 283 episodes were included for analyses. Hospital mortality was 32.9% (95%CI: 21.2-38.5). Only admission from a site other than the Emergency Care Department (OR 3.64, 95%CI: 1.30-10.20; p=0.01), moderate-severe liver disease (OR 5.65, 95%CI: 1.11-28.87; p=0.04) and the APACHE II score (OR 1.14, 95%CI: 1.04-1.26; p<0.01) and SOFA score at 72h (OR 1.19, 95%CI: 1.02-1.40; p=0.03) maintained a statistically significant relationship with hospital mortality. Conclusions: Delayed ICU admission, comorbidities and the severity of critical illness determine the prognosis of HIV-infected patients admitted to the ICU. Based on these data, HIV-infected patients should receive the same level of care as non-HIV-infected patients, regardless of their immunological or nutritional condition.[Resumen] Objetivos. Describir la epidemiología de la patología crítica en el paciente infectado por VIH durante la era de tratamiento antirretroviral de gran actividad actual y encontrar predictores de mortalidad hospitalaria. Métodos. Estudio observacional, retrospectivo y longitudinal que incluye pacientes infectados por VIH adultos ingresados en las UCI de hospitales de Galicia, entre el 1 de enero de 2000 y el 31 de diciembre de 2014. Analizamos variables demográficas y relacionadas con la infección por el VIH, comorbilidades, puntuaciones de gravedad, motivo de ingreso y necesidad de soporte de órganos. Empleamos la prueba de la Chi-cuadrado para comparar las variables categóricas y las pruebas de la T-Student, U de Mann-Whitney o H de Kruskal-Wallis para las variables continuas, asumiendo un error α = 0,05. Utilizamos la regresión logística multivariante para calcular la OR de la asociación con la mortalidad hospitalaria. Aplicamos análisis de regresión de joinpoint para estudiar la tendencia temporal de mortalidad. Resultados. Incluimos 283 episodios. La mortalidad hospitalaria fue del 32,9% (IC 95% = 21,2-38,5%). El ingreso no procedente de Urgencias (OR 3,64; IC 95% = 1,30-10,20; p = 0,01), la enfermedad hepática moderada-grave (OR 5,65; IC 95% = 1,11-28,87; p = 0,04), el APACHE II (OR 1,14; IC 95% = 1,04-1,26; p < 0,01) y el SOFA a las 72 h (OR 1,19; IC 95% = 1,02-1,40; p = 0,03) se relacionan con la mortalidad hospitalaria en el análisis multivariante. Conclusiones. El retraso en el ingreso en UCI, las comorbilidades y la gravedad del episodio determinan el pronóstico del paciente infectado por VIH ingresado en UCI. Los pacientes con VIH deberían recibir el mismo nivel de cuidados que los pacientes no infectados por VIH, independientemente de su estado inmunológico o nutricional

In-Hospital Post-Operative Infection after Heart Transplantation: Epidemiology, Clinical Management, and Outcome

Observational study[Abstract] Background: Infection is a major cause of morbidity and mortality after heart transplantation (HT). Little information about its importance in the immediate post-operative period is available. The aim of this study was to analyze the characteristics, incidence, and outcomes of in-hospital post-operative infections after HT. Methods: We conducted an observational, single-center study based on 677 adults who underwent HT from 1991 to 2015 and who survived the surgical intervention. In-hospital post-operative infections were identified retrospectively according to the medical finding in the clinical records. Results: Over a mean hospital stay of 24.5 days, 239 patients (35.3%) developed 348 episodes of infection (2 episodes per 100 patient-days). The most common sources of infection were those related to invasive procedures (respiratory infections, 115 [33%]; urinary tract infections, 47 [13.5%]; bacteremia, 42 [12.1%]; surgical site infections, 25 [7.2%]), in addition to abdominal focus (33, 9.5%). Enterobacteriaceae (76, 21.8%) and gram-positive cocci (58, 16.7%) were the predominant germs, although opportunistic infections were not infrequent (69, 19.8%). Ninety-five septic episodes were detected with a mean Sequential Organ Failure Assessment Score of 9.5 ± 5.3 points, with hemodynamic failure being the most severe organ dysfunction and renal dysfunction the most frequent one. Management included broad-spectrum antibiotics in 48.8% of episodes and surgical management in 13.8%. The overall antimicrobial success rate was 96.3%. Higher in-hospital mortality was observed among infected patients (15.1% vs. 10.3%), but this difference was not statistically significant (p = 0.067). The one-year survival and events were not different between patients suffering from a post-operative infection and those who did not. Conclusions: In-hospital infections were frequent in the post-operative period after HT and were associated with a poor short-term outcome. Patients who survived sepsis had a similar one-year morbidity and mortality compared with patients who did not develop an infection

Nosocomial pneumonia in the postoperative period after heart transplantation

Introduction Infections are a major complication during the postoperative period after heart transplantation (HT). In our hospital, nosocomial pneumonia is the most frequent infection in this period. The objective of this study is to determine the epidemiological and microbiological characteristics of this disease in our centre. Methods A descriptive retrospective study of all medical records of HT performed in a single institution from 1991 to 2009 followed until June 2010. Clinical and microbiological variables were considered. Centre for Diseases Control (CDC) criteria were used to define nosocomial infections. Invasive aspergillosis was considered if there were criteria for probable aspergillosis according to IDSA criteria. Results In 594 HTs there were 97 infectious episodes in 75 patients (12.6%). Eighty-f ve patients (14.3%) died during hospitalization. Infection is the second cause of mortality during the postoperative period (17.9% of dead patients). The most common locations of infections were pneumonia (n = 31, 31.9% of infection episodes), bloodstream (n = 24, 24.7%), urinary tract (n = 14, 14.4%), surgical site (n = 13, 13.4%) and intraabdominal infections (n = 13, 13.4%). Patients with pneumonia were treated according to knowledge in a specif c moment, thus different antibiotics were used. The duration of antibiotic therapy was 20 + 15.5 days. In nine episodes of pneumonia according to the CDC no germ was isolated in the cultures. Six of the episodes were polymicrobial infections. The most frequent microbes isolated were E. coli (n = 7, 22.5% of pneumonia cases), A. fumigatus (n = 7, 22.5%), S. aureus (n = 3, 9.68%), P. aeruginosa (n = 3, 9.68%), P. mirabilis, K. pneumoniae, E. cloacae, E. faecalis, C. glabrata, and S. marcescens (one case each, 3.22%). Pneumonia was suspected but not confirmed in 75 patients. Despite this, antibiotic treatment was maintained for a media of 17.35 + 7.01 days: 56 wide-spectrum treatments and 18 targeted therapy after k

In-hospital postoperative infection after heart transplantation: risk factors and development of a novel predictive score

[Abstract] Introduction: Infection is one of the most significant complications following heart transplantation (HT). The aim of this study was to identify specific risk factors for early postoperative infections in HT recipients, and to develop a multivariable predictive model to identify HT recipients at high risk. Methods: A single-center, observational, and retrospective study was conducted. The dependent variable was in-hospital postoperative infection. We examined demographic and epidemiological data from donors and recipients, surgical features, and adverse postoperative events as independent variables. Backwards, stepwise multivariable logistic regression with a P-value < 0.05 was used to identify clinical factors independently associated with the risk of in-hospital postoperative infections following HT. Results: Six hundred seventy-seven patients were included in this study. During the in-hospital postoperative period, 348 episodes of infection were diagnosed in 239 (35.9%) patients. Seven variables were identified as independent clinical predictors of early postoperative infection after HT: history of diabetes mellitus, previous sternotomy, preoperative mechanical ventilation, primary graft failure, major surgical bleeding, use of mycophenolate mofetil, and use of itraconazole. Based on the results of multivariable models, we constructed a 7-variable (8-point) score to predict the risk of in-hospital postoperative infection in HT recipients, which showed a reasonable ability to predict the risk of in-hospital postoperative infection in this population. Prospective external validation of this new score is warranted to confirm its clinical applicability. Conclusions: In-hospital postoperative infection is a common complication after HT, affecting 35% of patients who underwent this procedure at our institution. Diabetes mellitus, previous sternotomy, preoperative mechanical ventilation, primary graft failure, major surgical bleeding, use of mycophenolate mofetil, and itraconazole were all independent clinical predictors of early postoperative infection after HT